HR Tutorial for Formal Complaint of Discrimination



San José· Evergreen Community College DistrictHuman Resources5/18/2016Formal Discrimination Complaint Form ADDRESSBLOCK \f "<<_FIRST0_>><< _LAST0_>><< _SUFFIX0_>><<_COMPANY_>><<_STREET1_>><<_STREET2_>><<_CITY_>><<, _STATE_>><< _POSTAL_>>" \l 1033 \c 0 \e "" Completing the Formal Discrimination Complaint Form Any student or employee who believes they have been subjected to discrimination on the basis of their national origin, language/accent, disability (physical or mental), religion, ancestry, race, age (over 40), sexual orientation, color, immigration status, veteran status, ethnic group identification, marital status, gender identity, sex, medical condition, or perceived to be in any of the above protected category or associated with those in a protected category, may complete this form to seek redress. Please note this form is fillable and should be type written in adobe acrobat. The form can be printed when completed and then e-mailed to the appropriate Title IX Coordinator. Individuals may also choose to print out the form and complete it by hand with written attachments as necessary. Once the form is completed it should be submitted to Human Resources at the District Office room 212.Date- Make sure to date the form with the date you submit the formal complaint to Human plainant-This section is information from the individual who is completing the form. In most cases this should be the individual who experienced the discriminatory action. However, it is possible for a third-party to submit a complaint on behalf of another person. Your full name with last name, first name and middle name or initial should be placed on the first line. Your position title or student should be placed on the second line. Next, select the designation that most closely fits your association with San Jose Evergreen Community College District. Please note job applicants, vendors, contractors or community members may also file a formal complaint. You will need to check the location where the discrimination plaint is Filed Against- This space is for you to identify (name) those individuals or entities that subjected you to discrimination. This may be an individual, several people acting together, or a particular group (examples: student club, academic division or department, hiring committee, etc.) If you have contact information for this individual (address, cellphone number, or e-mail address) this information should also be provided. Please be aware that SJECCD can only investigate discriminatory acts against people within its direct control (students, faculty, or staff members) or those contracted to perform services on its properties. However, SJECCD will attempt to provide alternative resources to individuals experiencing discrimination from other sources, please contact Human Resources for further assistance. Identification of dates, specific location, activity or program in which the alleged discrimination occurred- These three lines provided are for you to provide brief summary information about the discriminatory actions. Please add additional pages as necessary. Basis of Discrimination- Check every box that you believe may apply to the discriminatory actions you experienced. Please review SJECCD Administrative Policy 3430 for guidance on these terms. Further assistance regarding the meaning and definitions of various types of discrimination can be found at statement-You can use the space provided to provide a detailed explanation of the harassment or discrimination you experienced. Please feel free to attach additional sheets as necessary to provide a detailed explanation. The statement should include responses to: who, what where, when and how. This statement should include any witnesses to each incident. If more than one incident occurred, please make sure to recount each incident of harassment or discrimination that you remember for the past year (if not employment case) or 180 day (for employment cases). Please note that AP3435 restricts all complaint look back periods to one year. Informal Complaint Resolution- Please attach a separate piece of paper to explain the outcome regarding any informal complaint procedure. If you have previously engaged in the informal complaint resolution process and were not satisfied with the outcome of that process, please explain what occurred and why you are filing a formal complaint. If you did not previously engage in the informal complaint procedure, please explain why you believe that was not an appropriate method to pursue. Specific Action Requested- In this space you should state either what remedy for yourself you are seeking, or what sanction \ disciplinary action you believe should be imposed on the individual causing the discrimination or harassment.Signature- Please remember to sign the complaint. Complaints received without a signature will be retuned with a request to sign before being deemed officially filed.Contact Information of Complainant- At the bottom of page two, please provide your name, address, and at least one phone number. If you prefer to be contacted by e-mail, please use the second telephone number spot to place your e-mail address. Please feel free to place a * (star) by the contact method you prefer. Witness information- On page 3 please identify any witnesses to the discrimination/ harassment. Please provide as much contact information (name, address, telephone and e-mail) as you know for each witness. If there are more than three witnesses, please use additional sheets to continue identifying witnesses. Document Hyperlink: Formal ComplaintLisa OwenHR Analystlisa.owen@sjeccd.edu408.274.6700 ext. 6586 ................
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